Awake Fibreoptic Intubation in a Patient with a Giant Multinodular Goitre and Retrosternal Extension: A Lesson in Structured Difficult-Airway Planning

Abstract

Background:
Giant thyroid masses represent a rare but potentially life-threatening anaesthetic challenge owing to the risks of tracheal deviation, extrinsic compression, and peri-induction airway obstruction. Retrosternal extension amplifies this hazard by concealing the true degree of mediastinal compromise from external examination and by worsening tracheal encroachment when the supine position is assumed. Careful pre-operative assessment and a structured, stepwise airway management plan are indispensable in this clinical context.
Case Report:
A 64-year-old woman with a 15-year history of multinodular goitre presented with a giant thyroid swelling (22×10 cm) and 1 cm of retrosternal extension. She had experienced two years of progressive exertional dyspnoea and was a known case of hyperthyroidism and hypertension, receiving carbimazole 5 mg twice daily and propranolol 10 mg once daily; she was in a euthyroid state at the time of surgery. Standard monitoring and a prepared difficult airway cart were in place before the procedure. Topical airway anaesthesia was achieved with nebulised 4% lignocaine and a hyoid block; intravenous fentanyl was administered for anxiolysis whilst spontaneous ventilation was maintained. Awake fibreoptic intubation was then performed; a size 7 cuffed endotracheal tube was placed under direct fibreoptic visualisation. General anaesthesia was subsequently induced. Volume-controlled ventilation was conducted (FiO2 0.60, tidal volume 450 mL, rate 12/min, PEEP 5 cmH2O, peak pressure 14 cmH2O, Pplat <25 cmH2O, ETCO2 35 mmHg); the intraoperative course was uneventful. Extubation was performed after a cuff leak test confirmed adequate airway patency.
Conclusion:
This case confirms that awake fibreoptic intubation is a safe and effective primary airway strategy for giant thyroid masses with retrosternal extension. A structured difficult-airway approach encompassing meticulous topicalisation, preservation of spontaneous ventilation, and cuff-leak-guided extubation is recommended to mitigate perioperative airway risk in this high-risk patient group.